A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure

Cohn, Jay N.; Johnson, Gary; Ziesche, Susan; Cobb, Frederick; Francis, Gary; Tristani, Felix; Smith, Raphael; Dunkman, W. Bruce; Loeb, Henry; Wong, Maylene; Bhat, Geetha; Goldman, Steven; Fletcher, Ross D.; Doherty, James; Hughes, C. Vincent; Carson, Peter; Cintron, Guillermo; Shabetai, Ralph; Haakenson, Clair

doi:10.1056/nejm199108013250502

Cited by 2,833Heart Failure Treatment and ManagementHeart rate and cardiovascular healthCardiovascular Function and Risk Factors

A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure

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Cohn, Jay N., Johnson, Gary, Ziesche, Susan, Cobb, Frederick, Francis, Gary, Tristani, Felix, Smith, Raphael, Dunkman, W. Bruce +11 more·1991·New England Journal of Medicine

DOI 10.1056/nejm199108013250502

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Abstract

BACKGROUND: To define better the efficacy of vasodilator therapy in the treatment of chronic congestive heart failure, we compared the effects of hydralazine and isosorbide dinitrate with those of enalapril in 804 men receiving digoxin and diuretic therapy for heart failure. The patients were randomly assigned in a double-blind manner to receive 20 mg of enalapril daily or 300 mg of hydralazine plus 160 mg of isosorbide dinitrate daily. The latter regimen was identical to that used with a similar patient population in the effective-treatment arm of our previous Vasodilator-Heart Failure Trial. RESULTS: Mortality after two years was significantly lower in the enalapril arm (18 percent) than in the hydralazine-isosorbide dinitrate arm (25 percent) (P = 0.016; reduction in mortality, 28.0 percent), and overall mortality tended to be lower (P = 0.08). The lower mortality in the enalapril arm was attributable to a reduction in the incidence of sudden death, and this beneficial effect was more prominent in patients with less severe symptoms (New York Heart Association class I or II). In contrast, body oxygen consumption at peak exercise was increased only by hydralazine-isosorbide dinitrate treatment (P less than 0.05), and left ventricular ejection fraction, which increased with both regimens during the 2 years after randomization, increased more (P less than 0.05) during the first 13 weeks in the hydralazine-isosorbide dinitrate group. CONCLUSIONS: The similar two-year mortality in the hydralazine-isosorbide dinitrate arms in our previous Vasodilator-Heart Failure Trial (26 percent) and in the present trial (25 percent), as compared with that in the placebo arm in the previous trial, (34 percent) and the further survival benefit with enalapril in the present trial (18 percent) strengthen the conclusion that vasodilator therapy should be included in the standard treatment for heart failure. The different effects of the two regimens (enalapril and hydralazine-isosorbide dinitrate) on mortality and physiologic end points suggest that the profile of effects might be enhanced if the regimens were used in combination.

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Compared with enalapril, treatment with H-ISDN provided less mortality reduction after a mean of 2.5 years (32.8% vs 38.2%; P = 0.016) and no difference in hospitalizations.
“Compared with enalapril, treatment with H-ISDN provided less mortality reduction after a mean of 2.5 years (32.8% vs 38.2%; P = 0.016) and no difference in hospitalizations.”
From CCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With Reduced Ejection Fraction (2021) · cites this paper as [78]
The Mortality section (p. 3) reports an average follow-up of 2.5 years and deaths of 32.8% with enalapril versus 38.2% with hydralazine–isosorbide dinitrate. However, P = 0.016 applies to the prespecified two-year comparison; the difference over the full follow-up had P = 0.08. The Hospitalization section (p. 5) reports no significant difference in the number of patients hospitalized. (LLM, conf=0.92)
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Authors: Cohn, J. N., Johnson, G., Ziesche, S., Cobb, F., Francis, G., Tristani, F., Smith, R., Dunkman, W. B., Loeb, H., Wong, M., Bhat, G., Goldman, S., Fletcher, R. D., Doherty, J., Hughes, C. V., Carson, P., Cintron, G., Shabetai, R., & Haakenson, C.
Affiliations: University of Minnesota (US)
ORCID: Cohn, Jay N.
Johnson, Gary
Bhat, Geetha
Venue: New England Journal of Medicine
Publisher: Massachusetts Medical Society
Published: 1991-08
Volume: 325
Issue: 5
Pages: 303-310
ISSN: 0028-4793 (ISSN-L)
1533-4406
DOI: 10.1056/nejm199108013250502
OpenAlex: W2046383587
Cited by: 2,833
References: 19
Citations by year: 2026: 14 · 2025: 15 · 2024: 26 · 2023: 21 · 2022: 31 · 2021: 27 · 2020: 46 · 2019: 39 · 2018: 51 · 2017: 56 · 2016: 69 · 2015: 59 · 2014: 54 · 2013: 61 · 2012: 56
FWCI: 124.25
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: New England Journal of Medicine (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart rate and cardiovascular health
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
Keywords: enalapril, hydralazine, isosorbide dinitrate, chronic congestive heart failure, vasodilator therapy, mortality, sudden death, exercise oxygen consumption, left ventricular ejection fraction, ACE inhibitors, combination therapy, digoxin, diuretics, NYHA functional class
MeSH terms: Adolescent, Adult, Aged, Chronic Disease, Death, Sudden, Double-Blind Method, Drug Administration Schedule, Drug Therapy, Combination, Enalapril, Physical Exertion, Heart Failure, Hospitalization, Humans, Hydralazine, Isosorbide Dinitrate, Male, Middle Aged, Norepinephrine, Oxygen Consumption, Patient Compliance, Stroke Volume, Survival Rate

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A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure

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